Combined single-stage osseous and soft tissue reconstruction of the tibia with the Ilizarov method and tissue transfer

OBJECTIVE: To determine the outcome of single-stage soft tissue and osseous reconstruction using the Ilizarov method and soft-tissue transfer. DESIGN: A retrospective review. SETTING:: A university-affiliated, tertiary-care center. PATIENTS/INTERVENTION: We identified 11 patients from a retrospective review from January 1994 to July 1999 who underwent single-stage soft tissue and osseous reconstruction using the Ilizarov method. All 11 patients had an initial traumatic mechanism to their tibia and had previous operative intervention before the combined procedure. The Ilizarov procedure was performed for infected tibial nonunion (8 cases), or complex fracture with soft-tissue loss (3 cases). MAIN OUTCOME MEASUREMENTS: Soft tissue transplant survival, union, range of motion, leg length discrepancy, the Association for the Study and Application of the Method of Ilizarov (ASAMI) score, radiographic parameters. RESULTS: There were 8 concomitant free tissue flaps and 3 local pedicled flaps. Two patients had primary bone grafting, and 5 others had addition of an antibiotic impregnated bone substitute. There were 8 cases of elective reconstructive surgery and 3 cases of acute traumatic fracture. The mean duration of Ilizarov application was 26 weeks (range, 7 to 42). Eight tibiae united primarily, and 3 healed after delayed bone grafting. There were 2 major flap complications. Both were successfully managed with repeat surgery. One patient sustained a repeat open fracture and subsequently received an amputation. According to the ASAMI score, there were 9 excellent results, 1 good result, and 1 poor result. CONCLUSION: Our study suggests that concomitant osseous and soft-tissue reconstruction with the Ilizarov technique and free or pedicled flaps is a viable option for patients with composite tissue defects.     

Simultaneous treatment of tibial bone and soft-tissue defects with the Ilizarov method

OBJECTIVES: To evaluate the potential for limb salvage using the Ilizarov method to simultaneously treat bone and soft-tissue defects of the leg without flap coverage. DESIGN: Retrospective study. SETTING: Level I trauma centers at 4 academic university medical centers. PATIENTS/PARTICIPANTS: Twenty-five patients with bone and soft-tissue defects associated with tibial fractures and nonunions. The average soft-tissue and bone defect after debridement was 10.1 (range, 2-25) cm and 6 (range, 2-14) cm respectively. Patients were not candidates for flap coverage and the treatment was a preamputation limb salvage undertaking in all cases. INTERVENTION: Ilizarov and Taylor Spatial Frames used to gradually close the bone and soft-tissue defects simultaneously by using monofocal shortening or bifocal or trifocal bone transport. MAIN OUTCOME MEASUREMENTS: Bone union, soft-tissue closure, resolution or prevention of infection, restoration of leg length equality, alignment, limb salvage. RESULTS: The average time of compression and distraction was 19.7 (range, 5-70) weeks, and time to soft-tissue closure was 14.7 (range, 3-41) weeks. Bony union occurred in 24 patients (96%). The average time in the frame was 43.2 (range, 10-82) weeks. Lengthening at another site was performed in 15 patients. The average amount of bone lengthening was 5.6 (range, 2-11) cm. Final leg length discrepancy (LLD) averaged 1.2 (range, 0-5) cm. Use of the trifocal approach resulted in less time in the frame for treatment of large bone and soft-tissue defects. There were no recurrences of osteomyelitis at the nonunion site. All wounds were closed. There were no amputations. All limbs were salvaged. CONCLUSIONS: The Ilizarov method can be successfully used to reconstruct the leg with tibial bone loss and an accompanying soft-tissue defect. This limb salvage method can be used in patients who are not believed to be candidates for flap coverage. One also may consider using this technique to avoid the need for a flap. Gradual closure of the defect is accomplished resulting in bony union and soft-tissue closure. Lengthening can be performed at another site. A trifocal approach should be considered for large defects (>6 cm). Advances in technique and frame design should help prevent residual deformity.     

Reverse sural flap cover within a ring fixator

The ring fixator is an ideal apparatus to treat infected gap nonunion of the tibia and to correct deformity in multiple planes. However soft tissue problems may arise during transport and at docking. Although various options such as free flaps, neurocutaneous flaps, fasciocutaneous flaps and cross leg flaps are available for flap cover, this is always done prior to application of a ring fixator. The versatility of the sural flap in terms of coverage of leg defects, ease of performing flap cover as well as its reliability and safety is well known. We describe an alternate way of treating soft tissue problems which occur at the lower third of the leg while being treated on an Ilizarov frame. We describe the surgical procedure followed in raising the flap and its anterior transposition within the Ilizarov frame in two patients.     

Transverse debridement and acute shortening followed by distraction histogenesis in the treatment of open tibial fractures with bone and soft tissue loss

This retrospective case series evaluates the technique of transverse debridement, acute shortening and subsequent distraction histogenesis in the management of open tibial fractures with bone and soft tissue loss, thereby avoiding the need for a soft tissue flap to cover the wound. Thirty-one patients with Gustilo grade III open tibial fractures between 2001 and 2011 were initially managed with transverse wound extensions, debridement and shortening to provide bony apposition and allowing primary wound closure without tension, or coverage with mobilization of soft tissue and split skin graft. Temporary monolateral external fixation was used to allow soft tissues resuscitation, followed by Ilizarov frame for definitive fracture stabilization. Leg length discrepancy was corrected by corticotomy and distraction histogenesis. Union was evaluated radiologically and clinically. Patients’ mean age was 37.3 years (18.3–59.3). Mean bone defect was 3.2 cm (1–8 cm). Mean time to union was 40.1 weeks (12.6–80.7 weeks), and median frame index was 75 days/cm. Median lengthening index (time in frame after corticotomy for lengthening) was 63 days/cm. Mean clinic follow-up was 79 weeks (23–174). Six patients had a total of seven complications. Four patients re-fractured after frame removal, one of whom required a second frame. Two patients required a second frame for correction of residual deformity, and one patient developed a stiff non-union which united following a second frame. There were no cases of deep infection. Acute shortening followed by distraction histogenesis is a safe method for the acute treatment of open tibial fractures with bone and soft tissue loss. This method also avoids the cost, logistical issues and morbidity associated with the use of local or free-tissue transfer flaps and has a low rate of serious complications despite the injury severity.     

Principles of free tissue transfer in orthopaedic practice

Free tissue transfer is a vital adjunct to orthopaedic practice; it may optimize the treatment of many emergency and elective conditions that require soft-tissue or bone augmentation. Consultation with a colleague trained in microsurgery is often necessary in undertaking free tissue transfer techniques. A two-team approach frequently is used to maximize efficiency and minimize fatigue. Flaps with reliable pedicle anatomy are preferred. Flaps typically are raised using an open technique, but endoscopic techniques can be utilized to decrease donor-site scarring. Free tissue transfer is a demanding procedure; careful preoperative planning is essential to ensure optimal results. Free tissue transfer inevitably results in some donor morbidity, and flaps are carefully chosen to minimize this. The most serious complication is failure of the flap. Free muscle flaps used in soft-tissue reconstruction today result in little loss of function.     

Preservation of bone flaps in patients with postcraniotomy infections

OBJECT: Management of postcraniotomy wound infections has traditionally consisted of operative debridement and removal of devitalized bone flaps followed by delayed cranioplasty. The authors report the highly favorable results of a prospective study in which postcraniotomy wound infections were managed with surgical debridement to preserve the bone flaps and avoid cranioplasty. METHODS: Since 1990, 13 patients with postcraniotomy wound infections have been prospectively treated with open surgical debridement and replacement of the bone flap. All patients received a full course of systemic antibiotic agents based on the determination of the bacterial culture and antibiotic sensitivity. Notable risk factors for infection included prior craniotomies, radiotherapy, and skull base procedures. The mean long-term follow-up period was 35 +/- 20 months. In all five patients who underwent craniotomies without complications, bone flap preservation was possible with full resolution of the infection and without the need for additional surgery. Among the eight patients with risk factors, bone preservation was possible in six patients, although two required minor wound revisions (without bone flap removal). Both patients who underwent craniofacial procedures required an additional procedure in which the bone flap was removed for recurrent infection (one after 2 months and the other after 29 months). CONCLUSIONS: In patients with uncomplicated postcraniotomy infections, simple operative debridement is sufficient and it is not necessary to discard the bone flaps and perform cranioplasties. Even patients with risk factors such as prior surgery or radiotherapy can usually be treated using this strategy. Patients who undergo craniofacial surgeries involving the nasal sinuses are at higher risk and may require bone flap removal.     

Extreme bone lengthening using distraction osteogenesis after trauma: a case report

We are reporting herein the result of a 22 cm tibial lengthening after using an acute shortening technique with acute temporary angulation for salvage of a posttraumatic lower limb injury. The patient was referred to our center 2 weeks after a Gustilo IIIB open complex injury to the lower limb that included bone and soft-tissue loss. After surgical debridement, the tibial gap was 22 cm and the soft-tissue defect on the anterior aspect of the calf measured 12 x 20 cm. An acute shortening using a 50 degrees angulation (apex posteriorly) of the tibia in an Ilizarov frame was done after a full assessment of all reconstructive surgical options. After complete wound healing, a progressive correction of the angulation was done. Bilevel tibial distraction at a rate of 1.75 mm/day restored the original lower limb length. The 22 cm tibial elongation included 17 cm proximal lengthening and 5 cm distal lengthening. The fractures consolidated after 371 days, all wounds had closed, and no signs of osteomyelitis were present. Good aesthetic and functional results were obtained. The patient had no leg discrepancy compared to his normal limb and he returned to his previous occupation as a garage mechanic and to his favorite sport, boxing. To our knowledge, this is the first report in the English literature of tibial lengthening of this magnitude following acute trauma.     

Novel skin graft donor site for the scalp transposition flap

Transposition scalp flaps are a versatile solution for soft-tissue cover in a multitude of scalp defects. They are frequently used to reconstruct larger skin cancers that involve the outer table of the cranium in addition to covering neurosurgical bony defects and hardware. The transposition flap requires the donor site to be grafted using a split-thickness graft, which results in a secondary wound elsewhere on the body, commonly the lateral thigh. Although quite routine in such surgery, this procedure does require another body area to be prepared and draped. We sought to streamline this procedure with an adjustment to the location of the donor site. In harvesting the graft from the skin of the flap itself, we localised all surgery to one area, which has a number of logistical and patient-care advantages. Our experience has shown significant benefits from this technique and this is now our chosen and recommended donor site for these reconstructions.     

一期植骨加内固定治疗手部开放性骨缺损

目的探讨应用一期植骨加内固定治疗手部开放性骨缺损的手术疗效。方法2000-2003年治疗手部开放性骨缺损12例；急诊采用彻底清创，自体髂骨植骨加钢板或克氏针内固定术治疗。其中7例因伴有皮肤软组织缺损同时行皮瓣移植术。结果11例创面I期愈合，其中6例皮瓣完全存活；1例皮瓣远端部分坏死，钢板外露，经皮瓣提升覆盖创面处理后愈合。术后随访1-3年，骨折愈合时间为2-6个月，平均3.5个月。手功能按TAM评定，优良率达82%。结论一期植骨加骨固定治疗手部开放性骨缺损能缩短病程，防止指体短缩，有利于手功能的恢复，彻底清创和良好的创面覆盖是手术成功的关键。     

The posterior tibial artery perforator flap: an alternative to free-flap closure in the comorbid patient

Wounds of the distal third of the leg with exposed bone traditionally require free flaps for coverage. Although this often provides good results, patients with multiple comorbidities cannot undergo the long operating times and multiple surgical sites required for these complex procedures. We reviewed the use of posterior tibial (PT) perforator flaps as an alternative to free flaps for distal leg wound coverage in ill patients. Six patients (mean age, 53 years) with multiple comorbidities that precluded free-flap closures were treated with PT perforator flaps to cover complex distal leg wounds. The most common comorbidity was cardiac disease. Five patients had Gustilo grade IIIB open tibial fractures and one had a chronic wound. Mean flap size was 8x5.5 cm with a mean of one perforator per flap. Mean operating room time was 103 minutes. Four flaps were done without general anesthesia. There were no perioperative cardiopulmonary events. With a mean follow-up of 15 months, all flaps survived and all patients were ambulatory. There were no cases of malunion, nonunion, infection, wound breakdown, or partial flap loss. The PT perforator flap is a reliable choice for patients with open leg wounds and comorbidities precluding free-flap closure.     

Free flap choice for soft tissue reconstruction of the severely damaged upper extremity

Reconstruction of complex wounds of the hand associated with severe bone, tendon, nerve and soft-tissue injuries has been a major problem in hand surgery. Early definitive soft-tissue coverage of this kind of extensive wound with well-vascularized tissue is one of the most important stages of reconstruction for salvage of the extremity and restoration of function. Although multiple free flap donor sites have been described for complex upper extremity wounds, the authors think that anterolateral thigh (ALT) and lateral arm (LA) flaps are good choices for soft-tissue reconstruction in the upper extremity because of their reconstructive characteristics. These flaps can be used as flow-through and also sensate flaps. There is no need for position change intraoperatively and two teams may work simultaneously. Donor sites can be hidden and there is no required sacrifice of major artery or muscle.     

骨搬移术治疗胫骨骨折术后感染性大段骨缺损的疗效分析

背景：胫骨骨折术后感染性大段骨缺损的发生率高,治疗困难,效果不理想。目前,骨缺损修复方法包括皮瓣覆盖＋自体骨移植术、异体骨或异种骨移植、带血供腓骨移植、骨延长和骨搬移术。目的：探讨骨搬移术治疗胫骨骨折术后感染性大段骨缺损的疗效。方法：选取2010年9月至2014年9月收治的胫骨骨折术后感染性大段骨缺损患者40例,男24例,女16例;年龄18~64岁,平均（42.8±12.1）岁。将患者随机分成两组各20例,一组采用Orthofix单臂外固定延长架截骨延长,另一组采用Ilizarov环形外固定延长架截骨延长,术后随访对比两组患者的手术时间、手术出血量、HHS膝关节功能评分、Baird-Jackson踝关节功能评分。结果：Orthofix单臂外固定延长架的手术时间较短、手术出血量较少,与Ilizarov环形外固定延长架比较均有统计学差异（P〈0.05）。两组患者的术后HHS膝关节功能评分、Baird-Jackson踝关节功能评分均较术前有明显提高（P〈0.01）。结论：骨搬移术治疗胫骨骨折术后感染性大段骨缺损的疗效佳,可较好地改善患者的膝关节和踝关节功能。其中Orthofix单臂外固定延长架能减少手术创伤,安全性较高,但骨搬运过程中容易发生延长骨成角和偏移;Ilizarov环形外固定延长架的术中应用置入较多钢针,移动时可造成部分皮瓣坏死和血管损伤,应避免在皮瓣覆盖创面的胫骨大段骨缺损患者中使用。     

Early use of microvascular free tissue transfer in the management of electrical injuries

High-tension electricity can cause devastating injuries which may result in major soft-tissue loss, limb loss and sometimes major threat to life. Deep structures may be exposed and require flap cover, but microvascular flap transfer in electrical burn has a comparatively high-failure rate. This article aims to evaluate the outcome of early reconstruction of such injuries using free tissue transfer. In the course of 3 years (2004-2006), 16 free tissue transfers were performed in 13 cases of electrical injury from 24h to 3 weeks after trauma. All flaps survived except one. The failure was due to vascular erosion and secondary haemorrhage. There was no incident of vascular occlusion. Thus, if wound debridement is meticulous and microvascular anastomosis is performed well away from the trauma site, free flaps should survive as well in electrical burn cases as in any other.     

Reconstruction of crush injuries of the foot dorsum: is the latissimus dorsi muscle flap a reliable choice?

Thirteen patients who underwent 13 latissimus dorsi free flaps for subacute foot dorsum defects were identified over a 4-year period. The average age of the patients was 30.5 years (range: 8 to 52 years). There were eight male, five female patients. The average follow-up was 23 months (range: 2 to 47 months). The soft-tissue defect resulted from motor vehicle accident in all cases. All of the patients presented with soft-tissue loss combined with extensor tendon and/or bone injury. The wounds were treated with serial debridement and free latissimus dorsi or latissimus dorsi-serratus anterior muscle and split-thickness skin graft coverage in all cases. The mean size of the flaps was 19 x 11 cm (range: 15 to 24 cm x 9 to 16 cm). Twelve of 13 flaps survived. Complications included infection (1 case), seroma in the donor region (2 cases), total flap failure (1 case), partial flap necrosis (2 cases), and wound dehiscence (2 cases).     

The Combined Use of a Pedicled Superficial Inferior Epigastric Artery Flap and a Groin Flap for Reconstruction of a Dorsal and Volar Hand Blast Injury

A hand blast injury case causing a large through-and-through composite tissue loss is presented. This injury resulted in a dorsal and a palmar hand defect with segmental bone loss. Soft tissue coverage of both dorsal and palmar wounds was achieved by two separate pedicle flaps with pedicles closely arising from the femoral artery: a superficial inferior epigastric artery (SIEA) flap and a groin flap. Simultaneously, a large iliac corticocancellous bone graft was harvested from the same incision to be used for the wrist fusion procedure. This approach uses two separate pedicled flaps with robust independent blood supply to cover simultaneously a dorsal and a volar hand wound. A large through-and-through hand defect can be reconstructed readily with this approach, and it is associated with much less perioperative morbidity compared to free composite tissue transfer options. The dissection of both the groin flap and the SIEA flap is straightforward and can be easily performed by a single surgeon. The combined use of these two flaps allows stable coverage of sizable dorsal and palmar wounds of the hand.     

小腿严重开放性骨折伴软组织缺损的治疗

目的 探讨小腿严重开放性骨折伴软组织缺损(Gustilo ⅢB型或ⅢC型)的治疗方法.方法 1990年1月至2008年12月,收治开放性胫腓骨骨折53例,其中Gustilo ⅢB型45例,ⅢC型8例.软组织缺损面积为6 cm×4 cm～18 cm×8 cm,8例伴骨缺损.急诊行骨折复位同定和血管修复,二期对软组织或骨缺损采用13种53块组织瓣移位或移植修复.骨折外固定支架固定35例,内固定16例,骨牵引及石膏固定2例.皮瓣或肌皮瓣47例,骨皮瓣6例.结果 51例获得随访,时间8个月～9年(平均18个月).骨折顺利愈合44例,愈合时间3.5～9.5个月,平均6.5个月.骨延迟愈合4例,骨不愈合3例,经手术植骨(5例)或骨外固定支架加压同定治疗(2例)均治愈.组织瓣移植53块,成活51块,坏死2块,成活率为96.2%.无截肢病例.结论 Gustilo ⅢB型或ⅢC型小腿严重开放性骨折,初期清创并采用以骨外支架为主的方法固定骨折,二期采用适当组织瓣移植修复软组织或骨缺损,是安全有效的治疗策略.     

Ipsilateral Fibular Transport Using Ilizarov–Taylor Spatial Frame for a Limb Salvage Reconstruction: a Case Report

Segmental bone defects of the tibia present a challenging problem, particularly when they are associated with soft tissue injuries or instability. Various techniques have been reported to treat bone loss in the tibia. This case report describes a patient with massive segmental bone loss associated with a soft tissue injury, which required a flap for coverage. The injury was treated with an ipsilateral fibular transport utilizing an Ilizarov/Taylor spatial frame. At one and a half year follow-up, the patient was able to walk without any support at home and wore a protective shell for outdoor activities. The outcome of this case study indicates that ipsilateral fibular transport using the Ilizarov method is a valuable technique for limb salvage reconstruction.     

Sequential chimeric medial femoral condyle and anterolateral thigh flow‐through flaps for one‐stage reconstructions of composite bone and soft tissue defects: Report of three cases

Small recalcitrant non‐unions with poor perfusion require reconstruction with vascularized bone flaps. Cases with concomitant large soft tissue defects are especially challenging, since vascularized soft tissue transfer is often indicated and distant microvascular anastomoses may be required. We introduce a sequential chimeric free flap composed of a medial femoral condyle corticoperiosteal flap anastomosed to an anterolateral thigh flow‐through flap (MFC‐ALT flap) and report its use for reconstruction of small non‐unions with concomitant large soft tissue defects in three exemplary patients. Two female and one male patients ages 39–58 years suffered from composite bone and soft tissue defects of the lower extremity and clavicle caused by tumor resection and postoperative radiation resp. infected tibial pilon fracture. The sizes of the soft tissue defects ranged from 15–23 × 4.5–6 cm and the sizes of the bone defects ranged from 1.5–4 × 2–4 cm. Defect reconstructions were performed in all cases with sequential chimeric MFC‐ALT flaps with sizes ranging from 2–4 × 1.6–4 cm for the MFC and 21–23 × 7–8 cm for the ALT skin paddles. Functional reconstructions were achieved in all cases resulting in stable unions and soft tissue coverage enabling the patients to bear full weight without assistance on 5‐months follow‐up. Postoperative course was uneventful and complications were restricted to a small skin necrosis at the suture line in one case. MFC‐ALT flaps may be a safe, and effective procedure for one‐stage reconstructions of small, irregularly shaped bone defects with concomitant large soft tissue loss or surrounding instable scarring, particularly in cases of recalcitrant non‐unions after radiation exposure.     

腓骨横向搬移治疗胫骨大段骨缺损

目的 探讨应用腓骨横向搬移术治疗胫骨大段骨缺损的方法与疗效.方法 2004年4月至2009年10月收治4例胫骨大段骨缺损患者,男3例,女1例;年龄14～62岁,平均27岁.胫骨缺损长度为13～25 cm.采用环形外同定支架固定,腓骨远、近端分别截骨后用2根橄榄针穿过腓骨固定于牵引器上,术后逐渐牵拉腓骨至胫骨骨缺损区,并于断端取髂骨植骨.结果 所有患者术后获12～60个月(平均34.6个月)随访.4例患者应用腓骨横向搬移修复胫骨大段骨缺损均获成功,治疗时间(安装外固定支架至拆除外固定支架时间)为12～26个月,平均19个月.全部患者伤口愈合良好,无感染复发,牵引过程中无神经损伤等并发症发生.2例患者有针道感染,均为表浅软组织感染,无需特殊处理,拔除牵引针后愈合.随着负重行走等功能锻炼,腓骨逐渐增粗,未发生再骨折.患肢功能恢复良好,均能完全负重行走.结论应用Ilizarov外固定支架进行腓骨横向搬移是治疗胫骨大段骨缺损的有效方法.

Abstract：

Objective To explore the therapeutic effects of ipsilateral fibular transport with an Ilizarov frame for treatment of massive tibial bone loss. Methods From April 2004 to October 2009, 4 cases of massive tibial bone loss were treated with an Ilizarov frame and ipsilateral fibular transport. They were 3 men and one woman, aged from 14 to 62 years (average, 27 years). Their tibial losses ranged from 13 to 25 cm. The whole tibia was first fixed with an external Ilizarov ring frame. Osteotomy was then performed at both distal and proximal parts of the fibula, before the isolated fibula was fixed to the Ilizarov frame with 2 olive wires. Next, the isolated fibula was gradually distracted to the site of tibial bone loss at a speed of one mm per day. Bone grafts were transplanted where and when the isolated fibula touched the tibia at last. Results The 4 patients were followed up for an average duration of 34. 6 months (range, 12 to 60 months). The external fixation time ranged from 12 to 26 months, (average, 19 months). Two patients had superficial pin site infection during fibular transport and healed spontaneously after removal of the pins. All the wounds were completely healed and no wound infection recurred. No nerve injury occurred during the fibular distraction.After full-weight bearing exercise, the isolated fibula became thicker gradually and no refracture happened.All patients regained good walking with full weight-bearing. Conclusion Gradual ipsilateral fibular transport with an Ilizarov frame is a reasonable and effective therapeutic method for patients with massive tibial bone loss.     

The lateral thoracodorsal flap as a salvage procedure for partial transverse rectus abdominis myocutaneous or deep inferior epigastric perforator flap loss in breast reconstruction

The transverse rectus abdominis musculocutaneous flap and deep inferior epigastric perforator flap are the flaps of choice for autologous breast reconstruction. The better understanding of the vascular anatomy of these flaps has reduced the incidence of flap loss and fat necrosis, and positioning the flap's least vascularized zone laterally in the newly reconstructed breast may limit partial flap loss to that area. Still, the resulting defect of such partial loss remains a challenge. We introduce the use of the lateral thoracodorsal flap as an easy and straightforward salvage procedure in such cases and present the history of 4 of our patients with a mean age of 45 years to illustrate this use. The procedure can be done as early as 6 weeks after initial reconstruction, reducing the burden of daily wound care for the patient and offering her an immediate restoration of the lateral contour of the reconstructed breast.